Rhinitis (Non-Allergic)

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Rhinitis (Non-Allergic)

Rhinology
Author Credentials 

Anne Getz, MD
Assistant Professor
Department of Otolaryngology—Head and Neck Surgery
University of Colorado
Aurora, CO

Module Summary

Nonallergic rhinitis (NAR) is a common inflammatory condition of the nasal airway which may be due to a variety of causes. As the name states, it is not caused by allergic disease, nor is it of infectious etiology. Diagnosis is made by ruling out allergic and infectious disease, as well as other inflammatory diseases such as chronic rhinosinusitis. Effective management depends on correct diagnosis of the underlying etiology of NAR and appropriate medical and, occasionally, surgical treatment.

Module Learning Objectives 
  1. Recognize the various types of nonallergic rhinitis (NAR) including nonallergic rhinopathy (vasomotor rhinitis), nonallergic rhinitis with eosinophilia (NARES), atrophic rhinitis, senile rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal-induced rhinitis, cerebral spinal fluid leak.
  2. Explain the work-up for the various types of nonallergic rhinitis. 
  3. Summarize the appropriate medical and surgical treatment options for nonallergic rhinitis depending on the type. 

Pathogenesis

Learning Objectives 
  1. Be familiar with the physiology behind the various types of NAR. 
  2. Understand associations of other underlying conditions with NAR. 
References 
  1. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice prameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.

Incidence

Learning Objectives 
  1. Know the incidence of NAR in the general population.
  2. Be able to identify at-risk groups for NAR. 
References 
  1. Bosquet J, Fokkens W, Burney P, et al. Important research questions in allergy and related diseases: nonallergic rhinitis: a GALEN paper. Allergy. 2008;63:842-853.
  2. Tran NP, Vickery J, Blaiss MS. Management of Rhinitis: Allergic and Nonallergic. Allergy Asthma Immunol Res. 2011;146-156.

Patient Evaluation

Learning Objectives 

Understand the diagnosis of NAR which focuses on ruling out atopy and identifying other underlying triggers or causes.  

References 
  1. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice prameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.
  2. Tran NP, Vickery J, Blaiss MS. Management of Rhinitis: Allergic and Nonallergic. Allergy Asthma Immunol Res. 2011;146-156.

Treatment

Learning Objectives 

Understand the appropriate treatment(s) for the various types of NAR (e.g. medical therapy, surgical therapy, environmental control measures, and medication avoidance). 

References 
  1. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice prameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.
  2. Tran NP, Vickery J, Blaiss MS. Management of Rhinitis: Allergic and Nonallergic. Allergy Asthma Immunol Res. 2011;146-156.

Medical Therapies

Learning Objectives 
  1. Understand the available medical therapies for NAR including intranasal saline, oral and intranasal antihistamines, intranasal anticholinergics, intranasal corticosteroids, and oral decongestants. 
  2. Be familiar with traditional and investigational therapies for NAR including capsaicin, silver nitrate, acupuncture, and surgery. 
References 
  1. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice prameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.
  2. Tran NP, Vickery J, Blaiss MS. Management of Rhinitis: Allergic and Nonallergic. Allergy Asthma Immunol Res. 2011;146-156.

Surgical Therapies

Learning Objectives 
  1. Understand the clear role of surgery for the specific case of CSF leak. 
  2. Be familiar with the less standard role of surgery for failed medical therapy in NAR, including vidian neurectomy for nonallergic rhinopathy (vasomotor rhinitis), surgery for severe septal deviation, inferior turbinate hypertrophy, or adenoid hypertrophy. 
References 
  1. Halderman A and Sindwani R. Surgical management of vasomotor rhinitis: a systematic review. Am J Rhinol Allergy. 2015;128-134.
  2. Marshal T, Yun WK, Hazout C, Sacks R, Harvery RJ. A systematic review of the evidence base for vidian neurectomy in managing rhinitis. J Laryngol Otol. 2016;Suppl 4:S7-28.
  3. Tran NP, Vickery J, Blaiss MS. Management of Rhinitis: Allergic and Nonallergic. Allergy Asthma Immunol Res. 2011;146-156.
  4. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Case Studies

  1. A 45-year-old female presents with complaints of paroxysms of sneezing, nasal pruritus and profuse, watery rhinorrhea. She has undergone recent intradermal allergy testing which was negative. She has tried several oral antihistamines with no improvement in her symptoms. What additional diagnostic testing might you perform on this patient? What treatment options would you try?
  2. A 38-year-old female presents with complaints of severe bilateral nasal obstruction worse at nighttime for the last 12 weeks. She denies any history of allergic rhinitis or chronic sinusitis. She has never had a sinus infection as far as she knows. She has tried saline spray which helps minimally. She has also used oxymetazoline nasal spray three times in the last 6 weeks, which does help for a few hours. She is hesitant to try other medications as she is 34 weeks pregnant. What is her most likely diagnosis? What other tests or procedures would you recommend? What treatment options would you consider and how would you counsel her?

Complications

Learning Objectives 

Understand the potential complications of medical and surgical treatment of nonallergic rhinitis. 

References 
  1. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice prameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.

Review

Review Questions 
  1. What are the various types of nonallergic rhinitis?
  2. What is the most the most common cause of nonallergic rhinitis?
  3. What are the treatment options for the various types of nonallergic rhinitis?
References 
  1. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice prameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84.
Resources 

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